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On-line version ISSN 2078-5135Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.98 n.11 Cape Town Nov. 2008

FROM THE EDITOR

Good riddance!

One could almost feel the earth tremble from the cheering when newly installed President Kgalema Motlanthe announced the removal of Dr Manto Tshabalala-Msimang from the health portfolio in the new cabinet. The nightmare was finally over. South Africa was rid of a health minister, once described as 'a drunk and a thief',1 whose bizarre views on HIV and AIDS had made her the laughing stock of the international community and an object of intense embarrassment here at home. In one of her more spectacular acts of buffoonery, she had the official South African exhibition stall at the 2006 International AIDS Conference in Toronto display garlic, lemon and beetroot as South Africa's remedies of choice in the management of HIV and AIDS, prompting a group of more than 60 international HIV experts, including Robert Gallo, co-discoverer of the HI virus, to write to President Thabo Mbeki to echo the numerous and repeated calls here at home for her to be fired. The calls were stubbornly ignored by President Mbeki.

But then the rug was pulled from under Manto when Thabo Mbeki himself was forced to resign the presidency under fire from his own ranks. Mbeki had gained notoriety for his denial of the link between HIV and AIDS. TAC's Zackie Achmat describes him as 'the Great Denialist' whose regime constituted 'the most hubristic executive in contemporary South Africa, characterised by the unrelenting denialism of the greatest threats facing our country, [among them] the HIV/AIDS catastrophe'.2 Unlike Nero, Manto and Thabo didn't just fiddle while Rome burned. They actively fuelled the HIV/AIDS inferno through their misguided policies, described by UN Envoy for AIDS in Africa as 'more worthy of a lunatic fringe than of a concerned and compassionate state'.3 According to TAC, over 2 million South Africans died of AIDS during Thabo Mbeki's presidency and Manto's custodianship of the health portfolio.

Manto, who graduated as a medical doctor from the First Leningrad Medical Institute in the Soviet Union in 1969, displayed astonishing ignorance of the fundamental principles of evidence-based science, believing for example that traditional medicines should not be bogged down in clinical trials, as 'we cannot use Western models of protocols for research and development'.4 Yet she felt confident enough to denigrate nevirapine and antiretroviral treatment as too toxic. 'All I am bombarded with is antiretrovirals, antiretrovirals' she complained at one stage. 'There are other things [we can do] to respond to HIV/AIDS in this country.'5 It took a Constitutional Court ruling and intense public pressure to force her and her cabinet colleagues to implement PMTCT and to roll out nationwide antiretroviral treatment.

'Don't just do something - talk!'

HIV and AIDS policy in South Africa would seem to have been jinxed from the very beginning. When the HI virus was first identified in South Africa during the mid-1980s, it was confined to the gay community and consequently received ambiguous and lukewarm reception from the apartheid regime, hamstrung by its own 'cultural taboos, xenophobia, Calvinist morality and prudishness'.6 When the heterosexual HIV epidemic broke out in the early 1990s before the democratic dispensation, the minority government lacked the political credibility to devise and implement an effective policy. The ANC, on the other hand, had acknowledged the threat of an HIV epidemic even before coming into power, and was instrumental in setting up, together with the minority government, the National AIDS Committee of SA (NACOSA), which put together a comprehensive and progressive 'AIDS Plan'.

That the ANC and the first democratic government, including Thabo Mbeki and Manto Tshabalala-Msimang, initially recognised and acknowledged the primary role of the HI virus in the causation of AIDS is therefore beyond debate. The problem, however, lay in the inclination of health minister Nkosazana Dlamini-Zuma and the Mandela government - born of naïveté or perhaps the human frailty articulated by Slavoj Žižek in the London Review of Books of 9 October 2008 that 'Faced with a disaster over which we have no real influence, people will often say, stupidly, "don't just talk, do something" [when it may be] time to step back, think and say the right thing' - to pursue quick-fix solutions without the necessary prior analysis, consultation and planning. Their hurried initiatives, undertaken without talking to experts, social scientists or civil society groups, resulted in the scandals of Virodene and Sarafina II that rocked the government and severely undermined its credibility in dealing with the HIV/ AIDS crisis.

Credit must however be attributed where credit is due. Throughout this entire period of HIV policy debacles, vacillation and denialism, health department civil service staff negotiated their way through the political minefield to do the necessary, such as counselling and testing, public education, condom distribution and keeping track of HIV prevalence among women attending antenatal clinics. They are the unsung heroes in this tragic drama. For them, the arrival of newly appointed Health Minister Barbara Hogan on the scene will not have been a minute too soon.